...before beauty

So many more patients on our service are my age than I'd like to count. They're all older – by 6 months, 3 months. There's an age I don't have to think about, looking at the year*. I know.

It's an adult service, and I'm going into adult medicine. But none of them, right now, are younger than me. No one should be and be this sick.

*yes, other times I get the subtraction wrong…

It’s HIV, AIDS, whatever CDC or WHO classification you’re using these days. Every patient I have, right now. Without exception.

When I was at the VA, first for emergency psych, and then later for surgery, it used to surprise me how all of my patients had been “in the service.” (strange thing to forget, when working in a hospital for veterans). Mostly in Vietnam, as the stereotype goes. History of mental illness, mostly, substance use, and then everything else that happens to so many sixty-odd-years old men. If you have private insurance, you don’t go the VA. There’s your demographic.

I’m not used to working with homogenous populations - by which I mean - when any of the rote descriptors were the same. The problem was partly surgery, where I barely knew the patients, anyway, didn’t meet them for much time prior to them being wheeled into the OR, and the surgeries would often repeat, within a day (if the patient comes in for surgery; ie, it’s not emergent, you might just meet them in anesthesia pre-op). And it’s the same procedure. Had I actually known them, had the time, the wherewithal to come in before 5 to have enough to do so and get the requisite work done - it would have been different.

Funny thing about the HIV** service, actually. I’m in the county hospital – where I want to be. Where I’ve wanted to be for so many years. We have translators on staff and on phones for a reason. But in 3 weeks, I haven’t used any of those resources. It’s not the demographic of the epidemic here – and that isn’t even true. Is it the demographic of those who are less likely to have been tested? Or, for some reason, not as many are as almost-dying? (Because more newly infected, maybe, relatively newer in the epidemiology?) I don’t know.

**I change how I answer the phone and introduce myself to patients, at times. “HIV consult room/ AIDS.” “with the HIV doctors.” And what do you say when the patient has a roommate? But doesn’t that apply to all conditions, really? No HIPAA in a hospital. Not within the rooms, among patients, their family and friends. 

 I’ve only done two weeks of inpatient medicine at the university hospital, for pediatrics. Kids, kids that sick, are eligible for Medicare. So they weren’t anyone in particular. There was the patient who lived on a reservation. The few in foster care/ adoptive situations suspicious of abuse or neglect. It’s the “better off” ones I don’t understand. Rather, I don’t understand why I’m there. Why there. I’m not needed. (and “I”, in this case, am anyone. Nothing in particular about me). It’s not what I want to be doing.

One thing about HIV is that Occam’s razor**** doesn’t apply. Ever. There is no need to connect a constellation of disparate symptoms – rather, you try, but it could very well, very likely, be multiple processes. Our service has been about three times busier than usual, apparently. I’ve seen almost every major opportunistic infection, at this point. With HIV, that’s the dangerous part, that’s what kills you – it’s not the virus itself. It’s the lack of immune system induced by the virus. Things that don’t make most people sick, do. Things that are rare, aren’t. You cease to be able to fight back – and everything, greedy everything – bacteria, viruses, fungus, parasites, and your own cells working against you (cancer) – takes advantage. Opportunistic. Opportunists. Who else preys on the down-and-out.

****House talks about this a lot. It’s more likely to be one process than many. Not here.

Why so sick. Why here. And why, with this disease, are they eligible for more services than people without this disease. In some ways. You can get aid to buy medication. You can get into clinics with multi-disciplinary services – the one here and another one I worked in have a psychiatrist on staff, social workers, case managers, people to help with housing, etc. There are pharmacies that are specialized in HIV medications (in this city, at any rate. But this was one of the initial epicenters), and you can ask them to make “blister packs” for patients. It’s a disease with many medications, but not always, not anymore. It was, what, 30 pills at one time. Now, you can get away with one per day. And depending on how good/bad your immune system is, a few more. Some patients are on seven, ten or so. And as the people, as the epidemic ages, they’ve got high cholesterol, maybe diabetes***, a lot have mental health issues as well, high blood pressure, etc etc etc…

***Though, in general, it’s one of the adult populations in the US with the lowest rate of obesity. The sickest ones, anyway.

But do pharmacies make blister packs for those patients? A Monday, Tuesday, etc; at least what I’m picturing. Is it available for anyone else? I’ve never heard of that. Not until now. I could be wrong.

Why this disease. Why now. I’ve seen babies die – almost never happens here, anymore. The rate I calculated for our health district in Cameroon was about 10%. One village was 25, 30%. But that’s one village, one place where truckers went through to Gabon. The country itself, though, is between 5 and 6% - lower than East, Southern Africa. When I was in Kenya, the rate in that health district was about 30%, over tens of thousands of people. Or more. For one island, it’s 90%, actually. One good thing – there’s no stigma at that point. Little. We had an obvious tent (and a few interior rooms) at a large hospital in town, everyone knew it was AIDS, but so many, so many people were there….

I don’t know what to say here. Or what not to say. What is the stigma, here. I’m sheltered, I’m in the health care system at a technically liberal, open-minded school in a technically liberal, open-minded city. A city with one of the highest prevalences of HIV in the US. I don’t know.

One patient, who’s been in the hospital a few weeks now, not getting better (I hope. I hope he is this weekend, did this weekend. Otherwise, he says he’s leaving on Monday), has started refusing daily labs because he’s so tired of getting stuck with needles. Bleeding, being bled. He’s a difficult stick, it seems, and in him, not because of IV drug use. (That’s the case for many patients I’ve seen. They “have no veins,” even for small blood draws, you have to put a central line in one of the largest neck veins. A jugular line, maybe. To have any access at all. The arm veins are all too scarred. When that isn’t the case, though, they’re less likely to create an easier port of access). But I’m a “difficult stick,” too. I could commiserate on the multiple times his skin was pierced to get one vial in the morning. (Up to seven, once, for me). I’ve since learned exactly which vein is easiest, and I show the phlebotomist every time. He does that too, but they’ve already used those many times. One morning, he told me how they missed, or didn’t get the tube connected (or disconnected) in time, and his blood spurted. I had a moment of terror. The interior recoil of “…it wasn’t me.” His blood, in my face, and as I pictured it, in my eye. It happened with a patient of mine, once, but she wasn’t HIV positive. (Actually, we didn’t test her. The potential exposure was essentially nil. It wasn’t worth it to go on post-exposure prophylaxis, not for that). What he described was maybe more, though. Knowing what’s in his blood. A lot of virus, maybe, probably, still. Rafael Campo has a story about that – it happened in the same hospital where I am now. Exactly one floor above, I imagine. Where the initial AIDS ward was. Exactly one floor above where this patient is now. It was the early nineties then, though. So much less known, so much less treatment at all. A poet exposed, my mentor exposed. I wasn’t, not this time. We-are-our-patients-are-us. What’s more human than that? A disease, an infection anyway, can jump. Person-to-person. It happens with non-human primates, too (current theories on how HIV mutated to be able to infect human hosts, from simian immunodeficiency virus (SIV). Another story). Monkey diseases can make us sick. Goat diseases. Pig diseases. Bird diseases. (Easy argument for evolution).

One of the intimacies of medicine. It’s amazing to listen to hearts, lungs again. To see, hear, feel, think, and learn. From all of that. But with this—the thing making my patient sick, the thing that’s been inside of so many of his cells, that’s been there (in his case) since at least the early eighties, when he was first diagnosed, that’s been making uncountable copies of itself, using him. Intercalating into his DNA, into the substrate that made him, him. And that thing, exactly, going into other people. Host to host. That little not-even-alive strand of molecules that starts to define him, in hospital (and elsewhere) parlance. “HIV patient,” “patient with HIV,” in the HIV/AIDS clinic, 58 year old man with HIV (and then we cite the current numbers of his infection. Disease). How many other, unchosen, permanent connections.

~j

"Weird it up."

My first semester workshop. And coming back to poetry after 6 years out of school for it, 8 years out of long-term, rigorous workshops (+ 1 week at Naropa a year before). I listen. To our brilliant, young, poetry prof (National Book Award finalist at 26, professor in creative writing 4? 5? years later, just published his first novel to critical acclaim...)
"Weird it up."

(Along those lines, another piece of poetry advice from that prof that I don't plan to do in medicine - "keep going with this until you fail. There's a project for winter break - write a book. And fail.")

Also: "I try 100, 500 lines until I get the right one."

So, I'm not right yet. But some poems do have 40 drafts. Average is 10, 12, for me.

I can't find the John Ashbery line I've heard quoted often enough, about how he knows something is done if he just keeps moving a comma.
Me: with current manuscript, still changing punctuation. And spacing. Right margin? Left margin? Middle? ...and does the fact that I put two periods at the end of one poem, rather than my ever-present and over-used ellipsis, look like a mistake, or something a poet might have done on purpose? Perhaps it should be one, then. Perhaps three. But two is so much more of what I wanted to convey, that incompleteness and hesitation and where on earth am I going with this line.(..). 

I'm on the AIDS consult service/clinics this month.

Things I can't do:
- draft patient notes 40 times. Let alone 10-12. Let alone 2.
- "weird up" my patient notes. Or make them rhyme.
- "weird up" the physical exam. Disease does that all on its own.

Day One

Day One

Year Four, Part Two.

It’s relearning this particular kind of efficiency, impatience with the IT guy on the phone when he doesn’t actually know what I’m talking about, taking the stairs not really for exercise but for time, and rushing, rushing everywhere. What a pager feels like. How many notes, papers, pens I might end up carrying and how to organize them. That I still remember where the stairs are, just carried there naturally,without thinking. After all, I used to write while walking, here, email while walking, where everything becomes rote, in a finite space. Only seven floors.

Remembering only with the third patient visit that, yes, appended to my name is supposed to be “medical student.” or “student doctor..." partly forgotten because any introduction with "poet" or "writer," while in writing school, felt self-important and uncertain. We used to discuss that - what it felt like to attach those names to ourselves. At what point. For what.

Impatience with the white coat. Impatience with the white coat.

So many things the same – nurses the same, wards the same (and why wouldn’t they be?) but a face recalls the patient we both had, a room, another one I wonder about. It’s a year ago. It isn’t. And every mistake (all. day) I make when trying to read paper or computer records recalls one I’ve made before. Once I figure out the answer. Second time around.

Some kinds of authority are still there. Walking in. Sitting down. Asking the questions that aren’t easy, asking and not being asked back. Though, today, “have you ever experienced anything like this?” (tuberculosis, isolation). Through my N95 particulate mask. Leaning forward. “No.” Another comparison she makes: “it’s like when you’re just waking up, between asleep and awake…that’s what the headaches feel like. That’s when the nightmares are.” I take human experience, my human experience, as evidence and descriptor. We are our patients are us are our patients.

I managed to hit most of the necessary points in the story. It’s a story, after all; any reader knows what she wants and needs to know. For the most part. “Felt like the house was moving.” Another line in my note. This part, I’ve done. This part, the listening, is poetry too.

The part slower to come back. Causing pain (“discomfort”), the importance of my exam, findings that I can actually report if they haven’t been reported before. Maybe. First day back. Full neuro exam. And putting the reflex hammer in the coat had felt superfluous, over-eager med student-like. But later I almost wished I had the needle points. The tuning fork. Pain, cold, pain. Vibration. I didn’t test proprioception – where are you in space, what is this room where people wander in so covered that no air escaping you, nothing of you into that air, could enter them.

Causing discomfort. My half-thought out, presented rationale “well, the patient was already doubled over in pain…so I didn’t do that part of the exam…”. Now I realize that that is the question – that pain (I didn’t cause it, I can call it “pain”) – the why. Why. And so tomorrow morning I have to go in and cause discomfort on top of the pain. My prerogative, our prerogative, the “greater good.” Of her, us, whomever else.

Poets? Pain, anything acute or acute-on-chronic or chronic-on-acute is a medium. The medium of poetry is image, the medium of fiction/literature/prose is the word (Ezra Pound, highly paraphrased/oversimplified).

There’s one thing the same. Poetry and medicine, with bodies as interlocutors. The use of poetry – fiction can’t describe simultaneity in the same way, conflation, distortion and ambivalence and reality within irreality within reality of an internal and external universe. Medicine is…the art of figuring out what the body is actually saying, and all we have are words, numbers, and some pictures (intrusions. inner) to describe. For poetry…it’s images, and we have words and space and placing (proprioception – where is this word, this phrase, this articulation, this sound. How is it related to anything else. How does it find itself).

Returning from a field that treats nebulousness with particularity and infinite variation with rigorous category and study. To another field that calls nebulousness particularity in word and in acronym, and organizes infinite variation into bell curves.

To the Venn diagram, scatter plot, Punnett square*, and any other shape used to cull entropic humans into a visible form.

~j

*poetry prof actually used that to describe one of my poems, the other day…